In deciding on the upper limit for blood pressure, your doctor is striking a balance between the risk of stroke and the hazards of falls from dizziness that older adults may experience.

Experts are reaffirming the importance of assessing each patient individually in the wake of a recent easing of guidelines for the upper limit of blood pressure for older adults – and the controversy that followed the guideline adjustment.

A minority group within the Joint National Committee (JNC) that recently reviewed and made changes to blood pressure guidelines for physicians disagreed with one committee recommendation: raising target blood pressure for patients 60 years and older from 140/90 to 150/90.

Balancing act

Minority opinion members on the JNC panel published their concerns in the April 2014 issue of the Annals of Internal Medicine. They say the recommended increase in blood pressure limits for those 60 years and older (absent diabetes or kidney disease) is unwise.

The JNC panel based the disputed recommendation, in part, on review of two large studies of older patients, many who were 70-plus years of age. The panel focused on the issue of balance and falls.

Leslie Cho, MD, Director of Cleveland Clinic’s Women’s Cardiovascular Center, says she understands the reasoning behind the JNC decision. “Looking at whether tight control below 140 was more beneficial, it turned out that the older you got, having lower and lower blood pressure was associated with dizziness and falling, which is a very, very serious complication in the elderly. So that is why JNC has embraced the 150/90 guideline,” Dr. Cho said.

Minority opinion objections

However, objectors say the change might:

Reduce the intensity of treatment for high-risk patients, including African Americans and patients with existing cardiovascular disease (CVD)

Reverse the successes achieved over recent decades in reducing deaths caused by CVD and stroke

Clinical experience

But Dr. Cho says, “What I have done … is, for any patient who is diabetic or who has evidence of renal dysfunction, regardless of age, we keep that blood pressure extremely tight, because we really believe in the notion that lower blood pressure is better for those risk factors.”

Despite the liberalization of blood pressure limits presented in the JNC, Dr. Cho says, “In general, we still for the most part, aim for the target of 140/90 for patients from 60 to 80 years of age.”

Increased stroke risk

Adding fuel to the fire is a recent study conducted at the Southern Medical University in Guangzhou, China that says even slightly elevated blood pressure adds significant risk of stroke.

Irene Katzan, MD, Director of the Center for Outcomes Research and Evaluation for Cleveland Clinic’s Neurological Institute, says she agrees with the Chinese study’s conclusions. “This concept of pre-hypertension or this slight elevation … is really important. The study estimates that … pre-hypertension is responsible for 20 percent of strokes and that is really significant,” she says.

Researchers found that people with pre-high blood pressure (blood pressure between 120/80 and 139/89) were 66 percent more likely to develop a stroke than people who had normal blood pressure. The study found that treating people with even a slightly elevated blood pressure could prevent many strokes.

Dr. Katzan stresses, “We know that high blood pressure – hypertension — is the most important modifiable risk factor for stroke. It’s responsible for 30 percent of strokes. And now this study suggests that even a slight elevation in blood pressure is significant.”

What is best

The bottom line for top limits on blood pressure? Doctors should continue to tailor treatments for their patients on a case-by-case basis. Many factors go into determining the best course of treatment for patients. Doctors need to rely on experience and focus on the individual for the best possible outcomes.